HomeMy WebLinkAboutTelephone Street Cut Permits Felt Road M
APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
A6t. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit
Date of Expiration 1540 SULLIVAN AVENUE Date -47J _
Ins. on File ( > Yes O No SOUTH WINDSOR, CT Permit Expires ¢-
Expiration Date FEE $25.00
Name of gw Firm A o� `tLZ�m*
Address of Firm � � -�� A Pho a No. A�` 1 Q
Location of proposed work 'T d Q OsI
` Despribe fuilly nature of permit requested _rb VU2k(_1E 126Ab C OP Du K
Starting date 06038
Approx. time for completion
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be /filed out by Town of SotM Windsor
two copies of separate drawing
Pavement Cut
Indic to North
Prop. size of cut
No, cuts
^� Amt. of Deposit $ by
PALE
Cash O Check #
Cut size after Perm Patch
M� Coto bko. S No. Cuts
C
Final Billing $
Aint. Due Payee $
Amt. Due Town $ .�
Applicant is responsible for contacting
the Police Dept. and C.B.Y.D. by date
I agree to funish to the Town of South Windsor the amount of bond required and to reimburse the Town of South Windsor
for any expenses incurred by the Town for maintenance or repair work in connection with this permit fnd that I am
familiar with and will 'de by the rules and regulations for permits as outlinqQ in the Town of South Windsor's Street Cut Permit Manual.
Sign d Title:
D.L.L.# Date: // /4 ?,T-
<R
PEFtMrT ITT ON JOBSITE AT ALL TIMES APPROVE , DATE:1//
'" 1 /Jar
TQMNGINEER
FOR INSPECTOR: Date work started Date Completed
- Signed bate
WHITE - PERMIT PINK - ST. SERVICES
YELLOW ENGINEERING GOLDENROD - FINANCE
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